Friday, May 28, 2010

The New York Times has published my LTE on former University of Chicago law professor Cass Sunstein, a leading advocate of so-called "libertarian paternalism".

My LTE was in response to their May 16, 2010 article in the Sunday Magazine section, "Cass Sunstein Wants to Nudge Us" praising his work as President Obama's director of the Office of Information and Regulatory Affairs (OIRA) to use his philosophy to push people into behaviours the government deems desirable, including health and financial matters -- i.e., the modern "behavioural economics" form of the nanny state.

The LTE will also be appearing this weekend in the May 30, 2010 print edition of the NYT in the Sunday Magazine section (as opposed to the main letters section of the newspaper). It's the second one down:

Cass Sunstein explicitly compares Americans to Homer Simpsons requiring government guidance to live. In my view, the proper function of government is to protect individual rights and freedoms. Unless we violate others' rights by force or fraud, the government should leave us alone to live according to our best judgment.

Of course, individuals may voluntarily "nudge" themselves to achieve long-term goals, like having your bank automatically deposit a portion of each paycheck into a child's college fund. But each person must make these decisions for himself based on his goals and circumstances. These choices are his responsibility and his right -- not the government’s.

Libertarian paternalism in essence says, “Don’t worry -- we’ll do your thinking for you.” If Americans start surrendering their minds thus to the government, they will become easy prey for demagogues and dictators.

The Massachusetts "health reform" disease means more than just bureaucrats setting prices. It also includes rising government spending and taxes; politicians demonizing doctors, hospitals and insurers -- and patients getting lectured that the restrictions of managed care are good medicine...

Government finally caring about the little guy? Hold your cheers -- because the inevitable next step is rationing at the point of consumption. Massachusetts state Senate President Therese Murray has proposed putting an end to "fee for service" medicine in the next five years and moving to a system of capitated managed care, where doctors receive a flat fee for each assigned patient.

This "HMOs for all" approach is designed to lead to soft rationing -- which, in medical terms, means people will have a hard time finding doctors or seeing the ones they have. It's already started. In Massachusetts, one doctor in two is not accepting new patients. Waits for treatment in Boston are the highest in the nation.

Tuesday, May 25, 2010

Gratzer critiques the ideas held by President Obama's new nominee to head Medicare, Dr. Donald Berwick. Berwick wishes to emulate the British "universal system", despite its serious flaws. Here's an excerpt:

Berwick has decades of experience in health policy and, on paper, would seem a perfect candidate for the job. But he has fallen into the trap of many intellectual elites, which we might call the Harvard Disease: assuming that a government committee can guide one-sixth of the national economy into efficiency.

In many ways, the Harvard professor represents all that is wrong with the Obama White House’s approach to health-care reform. As an unabashed admirer of Britain’s National Health Service, he sees only one solution: a 10-point plan, with more micromanagement by clever elites...

For more on Berwick's views, here's a chilling speech he gave in the UK two years ago praising their system as morally superior to the American system because it does a better job of "redistributing wealth":

The one thing I'll give him credit for -- he doesn't hide his socialist views under a facade of "moderation". At least Americans will have a clear idea of the ideology behind those who wish to assume control over our health care.

Many doctors worry that promised savings to their practices will not materialize. And there are plenty of examples of frustration with computers on the front lines.

"If this is a cost saver, I don't get it," says Dr. Michael Cohen, 49, a nephrologist in Wakefield who uses electronic records.

Cohen often can't send crucial patient information to other physicians because their systems are incompatible. He finds that the records contain so much data that important information can be buried. Mistakes in the records, he said, can be hard to detect and change.

"I agree that a good working system can be an incredibly powerful tool, but there's an incredibly steep learning curve," said Cohen.

In my own experience, electronic medical records can be tremendously helpful if their use evolves naturally in response to consumer needs, organically driven by market factors.

But when imposed by government fiat in a top-down fashion, they will almost certainly create more problems than they allegedly solve. Much of the increased operational "friction" in hospitals and physician offices won't be immediately obvious to patients, but hospital personnel and physician office staff will feel the crunch. Eventually, these increased costs in time and money will translate into higher medical costs or decreased medical services. Which means all patients will eventually pay the price.

Tuesday, May 18, 2010

The truth is the public option is alive and well, residing in Section 1334, pages 97-100, of the new health care law. That section gives the U.S. Office of Personnel Management -- which presently manages the federal civil service -- new responsibilities: establishing and running two entirely new government health insurance programs to compete directly with private insurance companies in every state with coverage for people outside of government.

Quoting the new law, former OPM director Donald Devine notes that it makes the OPM boss a health care czar, with power to set "'profit margin premiums and other such terms and conditions of coverage as are in the interest of enrollees in such plans.' That's open-ended. You can do anything." Dan Blair, another former OPM director, calls the new program "nothing but a placeholder for the public option." Indeed, the OPM head is also given the authority to "appoint as many employees" as needed to run the program, and to spend "such sums as may be necessary" to establish and administer it.

Monday, May 17, 2010

In the Galen Institute's May 14, 2010 health policy briefing, Grace-Marie Turner discusses the new "navigator" who will help you decide what kind of insurance to purchase:

Agents and brokers are on the front lines of navigating between health insurers, business owners, patients and health professionals, and the value they bring to the health sector is highly under-appreciated. Most of their clients are small and medium-sized businesses, and the agents basically serve as external human resources departments for them. They work hard to find policies to meet companies' needs (and budgets), hold seminars to brief employees on the benefit plans, and serve as intermediaries to make sure claims are paid and even help employees find physicians and the best hospitals.

The new health law indirectly acknowledges the value of agents by creating a new profession called "Navigators" for the new state health exchanges. But they won't be paid through the commissions that agents earn today. Instead, the Navigators will get government "grants" to help people select policies. The Navigators will, of course, more likely be beholden to politicians for their jobs than their clients. And once someone has a problem with a claim, good luck in getting them to help.

So when your employer stops offering health insurance because ObamaCare rules make it too expensive, and you're forced to fend for yourself in system of government-run "exchanges", will you be able to trust that your Obamacare "navigator" is really working for your best interests, rather than in the interests of his government paymasters?

Saturday, May 15, 2010

My theme is that the compromises that the insurance industry have made with the Obama Administration will merely lead to their own destruction and to a nationalized "single-payer" health system.

Here is the opening:

In early 2009, health insurance companies struck a Faustian bargain with the Obama administration. In exchange for a law requiring Americans to purchase health insurance, they agreed to regulations requiring them to offer coverage to all comers regardless of preexisting illnesses. Now that ObamaCare is law, insurers are learning that they may have sold their souls to the Devil -- along with the lives of the American people.

At first glance, ObamaCare might seem a good deal for insurance companies by guaranteeing them a market for their services. But this guaranteed market comes at a steep price, with the government dictating whom insurers must cover, what benefits they must offer, and what prices they may charge...

Some of the stuff we do have to fund, because the agencies are going to have to have staff to deal with the new requirements; and the stuff we don't have to fund is the demonstration projects that I was assured were going to bend the cost curve. So if we save this money in the first ten years, we lose the possibility of lower cost growth after the first decade.

What's really worrisome, however, is that I'm unaware of any happy surprises where it turns out this thing is going to cost less than expected.

Of course, voluntary "group appointments" can be perfectly fine if there are several patients with similar health problems willing to ask questions in front of other patients about issues of common concern. They can be a valuable adjunct to personalized appointments. But they cannot substitute for personal one-on-one time with a physician.

In the group setting, the patients are not allowed to remove clothing for proper physical examination due to the lack of privacy. In the video, Dr. Lindsey is shown auscultating and percussing through the patients' clothing.

As a medical student, I would flunk, that's right, flunk my standardized patient examinations if I even thought of auscultating or percussing through clothing. It is obvious that the lack of privacy even in the cardiology setting restricts the doctor from doing a proper physical examination.

Moreover, while the concept of a "medical home" sounds nice in theory, it can also be easily corrupted to become just another vehicle for rationing.

[Under ObamaCare,] Americans buying through the exchanges -- and as we've seen, that will soon be most Americans -- must get their care through something called "medical home." Medical home is similar to an HMO. You're assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. It was consumer outrage over despotic gatekeepers that made the HMOs so unpopular, and killed what was billed as the solution to America's health-care cost explosion.

Under the new "medical home" concept, the task of denying care is shifted from the government to the primary care physician (who may be operating under hidden government financial incentives to reduce referrals and control costs). As we've seen in countries like Great Britain, this pits the physician's interests directly again his patients' interests.

I fully support the concept of integrated personalized health care, where multiple specialists are coordinated by a primary physician working in the patient's best interest -- if patients and their physicians voluntary choose that approach with full disclosure and understanding on both sides.

But if such "medical homes" are made compulsory, then I am deeply concerned that Americans will be subjected to a nasty bait-and-switch, where their care is actually being rationed under the guise of "coordination" from their "medical home".

Thursday, May 13, 2010

"You oppose Medicaid and government-run schools? You're heartless and lack compassion." If you have ever made this accusation, even tacitly, I invite you to reconsider the government policies you support.

Why does being compassionate mean supporting government-run schools and health plans? This makes little sense if you view these programs as government-run charities. Would you agree to perpetually donate a portion of your monthly income to the same charity - regardless of its effectiveness? If the charity is doing a lousy job, wouldn't you want the freedom to find a better one?...

And at a deeper level, we need to examine the concept of whether there is any such thing as a "right" to health care or not. If one believes that there is, then the only question is how best can the government guarantee it. If one believes that there is no such right, then any attempt to manufacture one is fundamentally flawed from the outset.

These are precisely the sorts of ideas that need to be openly discussed and debated in America. And I'm glad that Brian Schwartz is raising some of these issues.

Wednesday, May 12, 2010

Your wife is stricken with a terrible medical condition. Her insurance benefits just ran out. You need money for her treatment.

You go to your next-door neighbor and tell him about your wife's misfortune. You demand $5,000.

Your neighbor is stupefied. Still, he expresses sympathy for your situation. He refers you to a registered charity and offers to connect you with someone who could help start a campaign to raise donations for your wife. He gives you a check for $100.

Your frustration mounts. Your emotional state is the equivalent of that which one feels from the recognition of a moral injustice, as if nature has the ability to inflict illness upon your wife by a conscious, concerted intent to rob her of her life.

Although your reason tells you no one is to blame, you let your mind obsess on the fact that your neighbor earns a lot more money than you or your wife. You rationalize that he really ought to give you more than $100, in the name of fairness, equality, social justice.

Indeed, you have gleaned through cultural sensibilities that, by right, you have some claim on the time, money, goods or services of others. Moreover, you hold that those who have should give to those who have not, as a matter of moral duty. You feel justified -- even righteous -- in compelling others to act in accordance with moral truth as you see it.

So you point a gun at your neighbor and demand more money. While you are uneasy about this, you repeat to yourself that you have the moral high ground; that, in the grand scheme of things, you are doing the right thing -- and so, too, will your neighbor, if he acquiesces.

Your neighbor begs you to understand that you have no right to initiate force against him. You grant this, for now, and put the gun away. But you have another plan.

Tuesday, May 11, 2010

Dr. Scherz, who is also president of the medical organization Docs4PatientCare opposed to ObamaCare, states the following about the AMA:

The AMA was not only a major supporter of ObamaCare but also an accomplice in its passage. Without the support of the AMA it is quite possible that the health-care reform initiative would have failed. So why the effort to silence other doctors? The AMA is not only worried about protecting this misguided legislation, it is worried about protecting itself.

...The irony is that in supporting ObamaCare and trying to silence doctors the AMA has forgotten its own mission statement and ethical code: "[T]o help doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues." It is always medically ethical to tell patients the truth, which is what doctors are now doing by educating them about ObamaCare.

Specificially, Schertz argues:

1) The AMA is attempting to inappropriately silence doctors speaking out to patients and the public against ObamaCare.

2) The AMA only represents 17% of physicians.

3) The AMA's political positions are not necessarily driven by any high-minded concern for patient welfare, but may be inappropriately influenced by a desire to retain special government-granted monopoly privileges over medical coding and billing standards, which can be quite lucrative for the organization.

Dr. Scherz raises many good questions. There may be some individual AMA members who are honestly mistaken in their support of ObamaCare, thinking it will benefit patients and doctors in the long run.

But many physicians I know are disgusted with the AMA's willingness to betray patients and doctors in exchange for questionable benefits, whether it be government-granted financial windfall (as Scherz argues) or the illusion of political clout from having "a seat at the table".

These employees would then have to find coverage on the state-run "exchange". Of course, if ObamaCare also drives private insurers out of business through a combination of mandatory benefits and price controls, then that would provide the government with the perfect opportunity to "rescue" the failing system with a single-payer government health plan.

The jaws of the government trap are being set. But Americans don't have to fall for it -- not if they are willing to fight to repeal ObamaCare.

Friday, May 7, 2010

...Another thing that struck me about the movie is how much it reinforced my existing political views about modern American medicine and health insurance. One person interviewed for the film claimed that often a C-section surgery is a legal strategy. The idea is that, if a doctor performs a C-section, he or she has made every possible medical intervention, and so cannot be sued. So the problems with American torts certainly show in this area.

I have long argued that third-party insurance payments -- entrenched by decades of federal tax policy and controls -- subvert individual responsibility. One women in the film said, "People in our culture spend more time and effort researching to buy a stereo system, a car, probably a camera, than they do checking out what their choices are for birth." In our third-party system of prepaid health care, most people have no incentive to seek out good value for their health dollars. Moreover, most people get the health care their employer's insurance company tells them to get, rather than the health care that would best serve their needs.

My wife and I, on the other hand, buy low-cost, high-deductible health insurance and pay for routine and expected care through our Health Savings Account. We're going to pay for our delivery by writing a check or running the debit card. We know what care we're getting and how much it costs. It is only if something goes terribly wrong, resulting in higher bills, that our insurance would kick in. ...

Unfortunately, those earlier government controls have led to yet further controls, which will further worsen the quality and availability of good medical care. How long will the downward spiral continue? The choice is ours.

Tuesday, May 4, 2010

Scott Becker explains how the AMA sold out physicians in its desire to "have a seat at the table" in the health care legislative process.

In short, the Obama administration needed their moral sanction and political cover for its agenda, and they desperately needed to be able to claim the support of doctors. The AMA sold its support for essentially nothing. Rather than having a "seat at the table", they instead put doctors on the menu.

Most physicians are not members of the AMA anyways (contrary to popular misconception). The recent ObamaCare debacle may drive more of them out, and into the arms of alternative groups such as the Docs4PatientCare.

As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D..

If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the "headache" that is actually an aneurysm, the "flu symptoms" that turn out to be meningitis, or the "gallbladder problem" that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.

As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase.

However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.

I do believe that patients and providers should be able to contract freely for medical services, and this includes so-called "mid-level providers" such as nurse practitioners. But Dr. Knope makes an important point -- namely,that you may not get the same level of care with a mid-level provider than with a MD.

To the extent that concierge physicians are allowed to operate, they potentially offer an excellent value for patients -- personalized service, individual attention, and high quality of care.

And as Dr. Knope points out on his own blog, these medical services can be surprisingly affordable. But he's also right about the wider issue of the corrosion of general internal medicine. The more Americans learn the truth, the better informed they'll be when the next round of health policy debates begin in earnest.

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.